1. Refugees and Asylum Seekers in Australia
This presentation outlines background demographics and information about refugee and asylum seeker health.
Refugee Health Fellow Program
May 2017 – do not use after May 2018

2. Legal status Refugee: Asylum seeker:
Someone who,“owing to a well founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality, and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country, or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it.”.
Asylum seeker:
A person who has left their country of origin, has applied for recognition as a refugee in another country, and is awaiting a decision on their application.
It is helpful to start with a definition for who a ‘refugee’ or ‘asylum seeker’ is and to know the difference
A refugee is someone who:
Has a well founded fear of being persecuted (according to grounds stated)
Are outside of their country of nationality
Are unwilling/unable to return
An asylum seeker:
A person who is seeking protection and is still waiting to have his/her claim assessed
Australia has international obligations to protect the human rights of all asylum seekers and refugees regardless of how and where they arrive, or whether they arrive with/without a visa.
See for more specific details on obligations under various international treaties.
UNHCR 1951 ‘Convention Relating to the Status of Refugees’ and 1967 ‘Protocol relating to the status of refugees’

3. UNHCR Global Trends 2015 65.3 M forcibly displaced 10M stateless
21.3M Refugees
40.8M Internally Displaced
3.2M Asylum Seekers
98,400 Unaccompanied Children
10M stateless
2013 Just surpassed > 50M with war in Syria, first time in the post-World War II era, exceeded 50 million people
2014 increased 8.3M and number of unaccompanied children – largest jumps in a year ever
1 in 113 people globally are displaced (about 1% of the global population)
This massive increase was driven mainly by the war in Syria, which by Oct 2015 had forced 4.2 million people into becoming refugees and made 7.6 million internally displaced (in total, over half of the pre-conflict Syrian populations)

4. UNHCR numbers – end 2015 Origin Destination 86% developing world
<1% resettled
These graphs show the country of origin for refugees in 2015
The destination for refugees is more than 80% will remain in developing countries, <1% settled annually
The countries that host the majority of refugees are developing countries
3 countries produce half the worlds refugees; SAR, afghanistan, somalia
Lebanon hosts 1 million, in country of 4 million – 1 in 5 refugees
Average length in refugee camp 15years

5. In 2015
Australia accepted 9,399 resettled refugees (3rd globally after US and Canada)
But ranks 69th for refugees to GDP per capita, and 63rd for refugees per 1000 inhabitants
UNHCR 2015

6. REFUGEE APPLICANT OFFSHORE ONSHORE Humanitarian entrant Asylum seeker
ORPHAN RELATIVE ONSHORE 837
OFFSHORE 117
OFFSHORE
ONSHORE
Humanitarian entrant
Asylum seeker
There are two main pathways refugees come to Australia
Offshore applicants who are recognised as refugees arrive in Australia with a Humanitarian Visa
On-shore applicants are asylum seekers – and arrive by boat or plane.
At various times, the boat arrivals have been referred to as “Unauthorised” “Illegal” “Irregular Maritime Arrivals” by DIBP. This language is depersonalises children and families.
Fleeing persecution is not a crime. Seeking asylum is a human right. It is not illegal to seek asylum without a visa. Around 80 percent of asylum seekers who come to Australia by boat are found to be refugees
AIR ARRIVALS*
‘ILLEGAL’/UNAUTHORISED/IRREGULAR MARITIME ARRIVALS

7. Australian Humanitarian Intake
Humanitarian Programme grants by category to 2014–15
Category
2012–13
2013–14
2014–15
Refugee
5984
5988
11985
6499
6002
Special Humanitarian (offshore)
2966
714
503
4507
5007
Onshore1
4828
7043
7510
2753
2747
Total2
13 778
13 745
19 998
13 759
13 756
1 Includes protection visas and onshore humanitarian visa grants that are countable under the Humanitarian Programme. 2 Data in this table is revised as at the end of the programme year, and may differ from previously published figures
These numbers represent Australia’s intake – annual intake (refugee category) set to increase to 18,750 in next four years.
Reference:

8. Arrival dates – policy (boat arrivals)
Before August 2012
Work rights
Retrospective application temporary visas
13 August 2012
Path – held detention -> Community Detention or Bridging Visa
2013 Temporary Visas
Subject to offshore processing (Manus Island, Nauru) – processing halted
No work rights
No family sponsorship
19 July 2013
Offshore processing, no resettlement
Prolonged held detention
If stayed in Australia – included in legacy caseload
15 December 2014
Migration Act amended – legacy caseload
These are the key dates in legislation affecting asylum seekers arriving by boat.
Note the change in path to held detention, community detention or bridging visa sine 2012 and path to offshore processing and no resettlement in Australia since The changes in 19 July 2013 resulted in prolonged periods of held detention.
Before Aug 2012 – bridging visas with workrights
Aug 2012 – detention centres re-opened
July 2013 – will not be resettled here
These are the key arrival dates relevant to AS
All groups face profound uncertainty

9. Numbers (31st Jan 2017)
Reference:

10. Pre-departure health screen (offshore)
Immigration Medical Exam - all
(Compulsory, 3–12 m prior to travel)
Hx/Exam
TB screen 2-10y
CXR ≥ 11y
HIV ≥ 15y
FWTU ≥ 5 yrs
HBsAg (preg/URM/HCW)
HCV (HCW)
Syphilis (Humanitarian) ly)
DHC - Humanitarian
(Voluntary – 3 d prior to travel)
Exam, parasite check
Malaria RDT and Rx if positive (location)
CXR and HIV if PHx TB
Albendazole ≥ 1 y
MMR 9m – 54y
+/- YF vaccine
+/- Polio vaccine
Ax local conditions
+/- Repeat IME
Character requirement
AUSCO
Outcomes
+/- Visa
Alert (Red. General)
Health Undertaking +/- delay travel
Outcomes
Fitness to fly assessment
Alert (Red, General)
+/- Health Undertaking
Pre-departure health screening consists of an Immigration medical exam, and then a voluntary Departure Health Check (DHC) within 3 days of travel to Australia.
New screening procedures have been implemented for Syrian and Iraqi arrivals, see next slide.
Australia
Post arrival health screening Voluntary

11. Pre-departure health screen (offshore)
Immigration Medical Exam - all
(Compulsory, 3–12 m prior to travel)
Hx/Exam
TB screen 2-10y
CXR ≥ 11y
HIV ≥ 15y
FWTU ≥ 5 yrs
HBsAg (preg/URM/HCW)
HCV (HCW)
Syphilis (Humanitarian) ly)
DHC - Humanitarian
(Voluntary – 3 d prior to travel)
Exam, parasite check
Malaria RDT and Rx if positive (location)
CXR and HIV if PHx TB
Albendazole ≥ 1 y
MMR 9m – 54y
+/- YF vaccine
+/- Polio vaccine
Ax local conditions
+/- Repeat IME
Syrian cohorts
Combined IME and DHC
Hx/Exam
TB screen 2-10 y
CXR ≥ 11 y
HIV ≥ 15 y
HBsAg
FWTU ≥ 5 y
Albendazole
Full 1st dose catch-up immunisations
Mental health screen
Development screen (<5 y)
Character requirement
AUSCO
Outcomes
+/- Visa
Alert (Red. General)
Health Undertaking +/- delay travel
Outcomes
Fitness to fly assessment
Alert (Red, General)
+/- Health Undertaking
VHA for all and extra DHC for Humanitarian, but note that kids get very little screening
YF details - All people > 1 yr old who have stayed 1 night+ in YF country within 6 days of flight to australia need YF certificate
Polio
All people departing from Pakistan, Cameroon and Syria will need to have a full course of polio vaccinations certified before they can leave the country.  
Refugee and humanitarian applicants will have one dose of OPV at the departure health check (and any new applicants referred for initial visa medical examination will also have a dose of OPV) in ten identified countries - Afghanistan, Cameroon, Equatorial Guinea, Ethiopia, Iraq, Israel, Kenya, Nigeria, Pakistan, Somalia and Syria. This will be documented by IOM on the health manifest, so it is clear to all health providers that this has occurred. (May 2014)

Australia
Post arrival health screening Voluntary

12. Onshore refugee health assessment
There is a refugee health assessment guide available for each state:

13. Suggested screening tests
Baseline
Age-based/risk-based screening
FBE & film
Ferritin
Hepatitis B serology (HBsAg, HBsAb, HBcAb)
Strongyloides serology
Tuberculosis screening (with TST≤5 years; and either TST or IGRA in older children)
Faecal specimen – OCP (ideally fixed to improve detection of protozoa), depending on pre-arrival albendazole
Vit D, Ca, PO4, ALP
Serum active vitamin B12
Malaria (endemic)
HCV serology
Schistosoma serology
Varicella serology
Rubella serology
STI screen (gonorrhea, chlamydia and syphilis)
HIV testing
Helicobacter pylori screening
These are the recommended screening tests in children. More details can be found here:

14. Prevalence (Australian data)
Anaemia Iron deficiency Low Vitamin D Low Vitamin A Low Vitamin B12 Hepatitis B Hepatitis C HIV Schistosoma Strongyloides Malaria Faecal parasites Mantoux test + STIs Syphilis Helicobacter pylori Inadequate immunisation
7 – 30% all groups, 23 – 39% < 5 years 13 – 30% % African, % Karen % African children 16 – 18% Afghan, Iran, Bhutan sAg 0 – 21%, sAb 26 – 60% 1 - 4% < 1% 5 – 38% African and South Asian 0 – 21% higher South Asian 4 – 10% African - prior to DHC, still get cases 11 – 42% all groups, higher children 10 – 53% 0% gonorrhoea, 0 – 6% chlamydia 0 – 8% adults, 0% children 82% African children 100%
These numbers reflect compiled prevalence data in Australian cohorts of patients, with regards to the conditions screened for.
These conditions are common and prevalence varies according to country of origin.
The prevalence of these conditions emphasizes the need for appropriate screening in refugee and asylum seeker background children

15. Mental health - consider
Country of origin situation
Migration journey
Detention experience/uncertainty
Torture/trauma
Sexual violence
Family separation/loss
Depression
Anxiety
PTSD
Self harm/suicidal ideation
Adjustment/grief/other
Developmental/behavioural impact (children)
Mental health is a significant issue and needs to be considered in all refugee background children.
Note that the mental health concerns may arise from various causes, including the detention experience as well as country of origin situation.
Children should be screened for mental health concerns at their appointments.

16. Violence & persecution Social & Psychological Effects
Core Components of Trauma Reaction
Recovery Goals
Killings, assaults
Life threats, threats of harm to family, friends
‘Disappearances’
Chronic fear & alarm
Disruption of connections to family, friends, community, & cultural beliefs
Destruction of central values of human existence
Humiliation
&
Degradation
Anxiety
Feelings of
helplessness
Loss of control
Relationships changed
Grief
Depression
Shattering of previously held assumptions:
Loss of trust
Meaning, identity & future
Guilt
Shame
Restore safety
Enhance control
Reduce the disabling effects of fear & anxiety
Restore attachment & connections to others who can
offer emotional support & care
Restore meaning & purpose to life
Restore dignity & value
Reduce excessive shame & guilt
Death
Separation
Isolation, dislocation
Prohibition of traditional practices
Deprivation of human rights
Killing on mass scale
Boundless human brutality on mass scale
An overview of the trauma pathway from violence and persecution to recovery goal.
Invasion of personal boundaries
No right to privacy
Impossible choices
Insults

17. Full plan: http://www.health.vic.gov.au/diversity/refugee.htm

18. A useful screening tool “ASK” when meeting with refugee families

19. For more information: Refugee Fellow Program Contacts:
RCH Immigrant Health:
Foundation House (VFST):
DIBP Fact Sheets: